Provider Demographics
NPI:1285145847
Name:LUNA, JUSTINE RAVEN (COTA)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:RAVEN
Last Name:LUNA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-2357
Mailing Address - Country:US
Mailing Address - Phone:254-242-8337
Mailing Address - Fax:
Practice Address - Street 1:900 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1200
Practice Address - Country:US
Practice Address - Phone:254-296-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-22
Last Update Date:2017-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214825225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics